VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at the Eastern Shore
23610 North Street
Onancock, VA 23417
(757) 787-4343

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: May 1, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ARTICLE 1 ? SUBJECTIVITY 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced renewal inspection took place on 05/01/24 from 8:50 am to 4:05 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: An addition of 10 rooms to the safe, secure unit was observed and measurements of the rooms was taken. Lunch and an activity were observed. A medication pass observation was completed for three residents. The following were reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-210-A
Description:	Based on the staff record review the facility failed to ensure in a facility licensed for both residential and assisted living care, direct care staff who are licensed healthcare professional or certified nurses? aide shall attend at least 12 hours of annual training. Evidence: 1. The record for staff #4, a certified nurses? aide, contains only 10.5 hours of annual training.
Plan of Correction:	What Has Been Done to Correct? Staff member has been instructed to complete additional training and to complete a minimum of 12 hours of training annually going forward. How Will Recurrence Be Prevented? Annual staff training will be monitored to ensure each staff member is completing a minimum of 12 hours of training annually. Person Responsible: BOM/ED
Standard #:	22VAC40-73-210-F
Description:	Based on the staff record review the facility failed to ensure at least two of the required hours of training shall focus on infection control and prevention. Evidence: 1. The record for staff #4 did not contain two hours of annual training focused on infection control and prevention.
Plan of Correction:	What Has Been Done to Correct? Staff member has been assigned and completed 2 hours of infection control and prevention training in Relias. How Will Recurrence Be Prevented? Annual staff training will be monitored to ensure that all direct care staff will complete a minimum of 2 hours of infection control and prevention training in Relias. Person Responsible: BOM/ED
Standard #:	22VAC40-73-320-A
Description:	Based on the record review the facility failed to ensure within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility and shall contain the following: Results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form. Evidence: 1. The record for resident #3, admission date 09/22/23, does not contain a risk assessment for TB completed within 30 days prior to the resident?s admission date.
Plan of Correction:	What Has Been Done to Correct? All resident files will be audited to ensure a TB assessment form is present. Any resident whose files do not include a TB assessment form will have one completed and included in their file. How Will Recurrence Be Prevented? All new residents will be screened for TB prior to admission into the community. Person Responsible: BOM/RCD/ARCD
Standard #:	22VAC40-73-410-A
Description:	Based on the record review the facility failed to ensure upon admission, the assisted living facility shall provide an orientation for new residents and their legal guardian including emergency response procedures, mealtimes, and use of the call system. Acknowledgement of receiving the orientation shall be signed and dated by the resident and, as appropriate his legal guardian, and such documentation shall be kept in the resident?s record. Evidence: 1. The record for resident #6, admission date 03/22/23, did not contain documentation of an orientation.
Plan of Correction:	What Has Been Done to Correct? Resident has received orientation to include emergency response procedures, mealtimes and use of the call system. How Will Recurrence Be Prevented? All new residents will receive orientation and sign acknowledgement upon admission to the community. Person Responsible: ED
Standard #:	22VAC40-73-680-D
Description:	Based on the record review the facility failed to ensure medications shall be administered in accordance with the physician?s order. Evidence: 1. Resident?s #4 physician order dated 02/16/24 and medication administration record (MAR) includes an order for Metoprolol SUCC ER 25 mg Tablet, ?take ? tablet (12.5mg) by mouth twice daily, Hold for Systolic less than 120 and/ or HR less than 60.? Resident?s # 3 MAR documents the resident was administered the Metoprolol on the following dates when the resident?s systolic was documented as less than 120: 04/02/24, systolic 101 04/05/24, systolic 109 04/06/24, systolic 114 04/10/24, systolic 104 04/15/24, systolic 97 04/19/24, systolic 115 04/20/24, systolic 100 04/21/24, systolic 116 04/29/24, systolic 108
Plan of Correction:	What Has Been Done to Correct? An in-service was conducted to review overall administration of all drugs and specifically Metoprolol with orders to hold for specific systolic and heart rate. How Will Recurrence Be Prevented? RCD/ARCD will review orders to assure complete and accurate; they will monitor MAR documentation to assure meds are being administered per physician?s orders. Person Responsible: RCD/ARCD/ED